Topic: Burns
What is Burns ?
Burns are injuries initiated due to therma l, chemical, electrical, physical agents of
local and systemic repercussions or effects. Also, burns are considered to be one of
the most mortifying forms of traumatic injuries as it has caused so many victims to
suffer severely through the years.
Thermal burns are due to sources of heat that would significantly increase the
temperature of the skin causing damage of skin and cells.
Radiation burns are caused by being exposed to sources of radiation for a long
period of time such as sunlight and x -rays.
Chemical burns are caused by strong chemicals coming in contact with the skin or
eyes such as acids, detergents, alkali, etc.
Electrical burns , from its name is from electrical currents which could be direct or
alternating currents.

Classification of Burns
When classifying burns, the extent and depth of the burns are the most important
factors to be considered.
The extent of a burn is usually calculated by %TBSA (percentage of the Total Body
Surface Area) that has been burned. This could be done through sev eral methods
such as:
? Rule of Nines

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? Lund and Browder Chart
? Palmar Surface
The depth of a burn depends on how deeply and how severely a burn injury has
penetrated the skin’s surface. The burn depths are classified as degrees:
? First -degree Burns (superficial): affect epidermis or outer layer of
skin. Burn site is red in color, painful, dry and has no blisters. Could
be caused by mild sunburn where long term damage of the tissue is
rare.

? Second -degree Burns (partial thickness): affect epidermis and
part of the dermis layer of the skin. Burn site is red in color,
blistered, could be painful and appear to be swollen.

? Third -degree Burns (full thickness): the epidermis and dermis
are destroyed and could affec t the subcutaneous tissue, the burn
site may be white or charred.

? Fourth -degree Burns : damage the underlying bones, muscles, tendons and
destroy the nerve endings resulting in no sensation in the area.

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Assessment of Burns Using: Rule of Nines
Assessing a burn using the Rule of Nines is used to make the right treatment decisions
including fluid replacement or resuscitation – due to extreme fluid loss caused by
removal of the skin barrier on burn victims . The percentage of total body surface
area (%TBSA) that has been burned is estimated in multiples of nine.
The Rule of Nines is usually used in adults more than infants to assess second -degree
and third -degree burns as they are more severe and more traumatic than first -degree
burns. The percentage s are estimated based on different body areas:
? The Entire Head: 9%
? The Entire Trunk: 36%
? The Upper Extremity: 18%
? The Lower Extremity: 36%
? The Groin: 1%
(Note: each body area is divided into posterior – anterior OR right –left, depending
on the area. For example, the head = 4.5% anteriorly, 4.5% posteriorly.)
The factors that could slightly affect the Rule of Nines are the Body Max Index
(BMI) and age of the burn victim.

Effect of Burn Injury
Severe burn injuries tremendously effect the body. Burn victims usually go through
metabolic stress, meaning they become hyper metabolic and almost everything in
the body te nds to work faster. The blood pressure rapidly increases as well as the
heart rate, nutritional needs and pain – pain management becomes a priority.

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If the case is severe enough it could cause multiorgan failure where the heart could
shut down and the lun gs may be brutally affected. Along with that, these failures
could also lead to the victim’s kidneys to shut down and possibly infect the liver.
Extensive burns could also affect the immune system (generalized suppression).
Burn victims become more prone t o bacterial infections, this is due to depressed
complement levels and the reduction of neutrophil chemotaxis as well as
cytotoxicity.
Burns could cause both local and systemic responses : if the burn is less than 25% of
the total body surface are (TBSA) it causes a local response, if the burn is more than
25% of the total body surface area (TBSA) it produces both local and systemic
responses – considered more major injuries.
Still under the metabolic stress response, there is also an inflammatory hyper
catabolic response where there are higher levels of cytokines. These cytokine levels
elevate persistently and are directly related to age as well as the severity of the burn.
Major burn injuries could also effect :
? The Skeletal Muscles.
? The Bones.
So, the effects of burn injury on skeletal muscles include the turnover of muscle
protein, alteration of the protein metabolism and the mediators and of course the
functional impacts – muscle cachexia. These changes would t remendously impact
the locomotion and homeostasis of protein, lipids and glucose metabolism.
Muscle Protein Turnover in Burn Patients : The body proteins constantly synthesize
and break down resulting in a decrease of muscle mass also leading to an inadequate

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count of amino acids. This could cause organ failure as there may be a decrease in
blood circulation to specific organs.
Mediators of Altered Protein Metabolism Following Burns: Other th an the
breakdown of body proteins and amino acids, there are still factors such as the
resistance to insulin, the increase of stress hormones, an elevation of muscle wasting
after burn. Immobilization is also another factor, which is usually caused by the
several surgical procedures of more severe cases. Being bedridden or immobilized
postop increases the muscle deterioration or wasting.
Muscle Cachexia: A wasting syndrome where there is a significant loss in weight,
muscle (atrophy) and appetite. A burn su rvivor with this syndrome would face
fatigue, an increase in psychological distress, limitations of motion and self -care.
Effect of Burn on Bone: Severe burns cause an increase in bone resorption and
osteoclasts. There could also be a great chance of osteoporosis, significant decrease
in bone mass, etc.
There are so many effects all according to the severity of the burn, keep in mind that
burn survivors might not only be effected as an individual but the whole family or
caretaker would also be affected as they would have to provide assistance during
recovery.

The way you react and treat a burn during the first minutes after being injured can
really affect how severe the injury could get.
First Aid, immediate treatment:
Burn victims must “Stop, Drop & Roll” to put out any live flames and victims should
remove any burned clothing. If any clothing tends to stick to the skin DO NOT pull
on it, just cut around the burned area where it is adhered. Also any jewelry, tight
clothing or belts should be removed from burned areas and around the neck as the
skin starts to swell immediately after a burn.
Medical Management , treatment slightly differs depending on type of burn:
? First -degree Burns:
Apply or immerse in cool, fresh water until pain is reduced.
Cover the burn with sterilized – non -adhesive bandages or cloth.
Pain medication may be used to reduce pain and inflammation.
Seek medical attention only if the burn covers a very large area.

? Se cond -degree Burns:
For ten to fifteen minutes immerse area in fresh, cool water (dry & cover with clean
cloth, sterilized gauze).
DO NOT break blisters.
Take steps to prevent shock (lay flat, feet elevated approximately twelve inches,
covered with coat or blanket) – DO NOT take these steps if head, leg, back or neck
injury is suspected or even if it is just too discomforting.
Further medical treatment is a must.

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? Third -degree Burns:
Cover burn (with material that will not leave any lint residue on the burn) .
Take steps to prevent shock.
If the face is burned, the victim must sit up – beware of any breathing problems.
Burned area should be elevated above head if possible.
IMMEDIATE medical attention is required.

(In all types of burns do not use any ointment s or butter on the burns as it may cause
infection)

Surgical Management, Managing the Wound:
For any surgical intervention to succeed, the right operation must be done at the right
time. The two basic concepts that are used to manage a burn wound are: 1) Delayed
excision, and 2) Early excision. Depending on how severe the burn injury, it might
be required to apply both concepts but it is more common in most cases to use the
delayed excision.
After reconstructive surgery in severe cases, the patient may have to go through the
process of removing dead tissue. Then comes the plastic surgery intervention which,
according to the case, a treatment is chosen.
In plastic surgery several treatments are used, including:
? Skin Grafts : are the most common when treati ng burn patients, it is where skin
is removed from one are of the body and is transplanted and relocated where
needed.

? Microsurgery : during a burn incident, the patient may lose a finger, a toe, an
ear or even a lip in some cases. This treatment, these bo dy parts can be re –
attached and this surgery is usually used with the free flap procedure.

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? Free Flap Procedure : a procedure used during reconstruction where the
muscles, skin or the bones are transferred within the original blood supply (in
transplants).

? Tissue Expansion : this procedure is used to help the patient’s body kind of
“grow” extra skin, which could be needed in reconstruction surgery. The skin
is stretched by applying a balloon expander under or near the area in need of
repair. Th is causes the tissue to expand (stretch ; grow), then it is used to
basically reconstruct or correct the areas or body parts that were damaged
during the burn.

In conclusion, the techniques always vary according to the severity of the burn and
the age of the victim. Burns are very severe traumatic injuries which have the
possibility of affecting all ages. The steps to help a victim should be taken very
seriously to avoid worsening the patients status.